Hospice of the South Coast LLC

“Upon patient record review, 2 of 14 (Patient #1,#7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1:The medication profile includes an entry for MiraLAX 17 mg po daily for constipation. There is no evidence on the medication profile that the entry includes a type and amount of diluent for administration. The medication profile includes an entry for Oxygen 2 liters per minute as needed via nasal cannula while the plan of care includes an order for oxygen 1 liter per minute as needed via nasal cannula. There is no evidence that the entry on the medication profile has the correct liter flow. COS Patient 7:The medication profile includes entries for acetaminophen 650 mg supp every 6 hours and acetaminophen ER 650 mg q 4 hours. There is no evidence that the entries include a warning to not exceed 4000 mg of acetaminophen daily.”

“Upon patient record review, 1 of 14 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 2: The medical record includes nursing documentation that the patient reported pain with movement during care and that she requested pain medication be administered by the facility nurse. There is no evidence in the documentation that the patient received pain medication or the status of the patient’s pain prior to the end of the visit.”

“Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 7:The medical record includes nursing documentation on admission that the patient has a history of rectal and anal bleeding as well as an entry on the medication profile of aspirin for anticoagulation. There is no evidence that the plan of care includes problems, goals and intervention related to the risk of bleeding.”

“Upon patient record review, 2 of 14 (Patient #1,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1:The plan of care includes an order for MiraLAX 17 mg po daily for constipation. There is no evidence on the plan of care that the order includes a type and amount of diluent for administration. The plan of care on admission includes an order for wound care for a stage 2 pressure ulcer to coccyx that notes cleanse with saline and pat dry, apply zinc oxide and cover with bordered foam. There is no evidence that the order includes the frequency for the treatment or who is to perform care. Patient 5:The plan of care includes a wound care order on admission to cleanse buttock wound daily and cover with Band-Aid or other dressing provided for sheer protection. The nursing documentation notes that there are wounds to right and left buttocks. There is no evidence that the order includes an exact location of the wound, a specific dressing to cover wound and who is to perform wound care.”

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 8:The Aide plan of care included the tasks of change linens and turn and reposition patient with the noted frequency as “per HHA”. There is no evidence of a acceptable frequency for the tasks.”